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Saturday, March 31, 2012

Milah U'Priah B'Vas Achas

The title refers to removing the foreskin and the membrane below it in one action. There are different ways to do this:

My teacher, Rabbi Mordechai Sasson, would often grab the foreskin with his fingers and remove all of the membrane along with it, alleviating any need to tear the membrane or otherwise remove it.

Others accomplish the same task with the help of an instrument called a "hemostat"

Still others do what Rabbi Sasson did, except they only remove part of the membrane. The remaining membrane is then torn apart with the fingernails (which can be gloved, if the gloves are thin) and folded back beyond the corona of the glans. This third approach does not completely remove the membrane as do the first two methods described.

I recently had someone ask me why I follow the second approach listed, especially in light of my training. Following the advice of one of my teachers, who is of the opinion that the fewer things needed to be done to a baby (as in "cut once" as opposed to "cut and then tear") the better, I have opted to act in accordance with the approach advocated by Rabbi Moshe Feinstein in his responsa on this subject. The most clear cut analysis is in YD 3:98 (as noted below), in which he quotes this - from the Geonic Period:

Rabbi Feinstein even writes that when he first discussed this topic he had not yet seen (or known about) the passage I just reproduced above (knowledge of which I only have from reading Rabbi Feinstein's letter), but since his halakha analysis brought him to the same conclusion, it is clear that it is a proper practice to remove the foreskin and membrane together.

Every person has the ability to educate oneself about the methods out there, and choose what works best for you. You can hire a mohel telling him exactly what you want him to do, and see if he will accommodate your wishes based on his comfort level. And if it doesn't work in either direction, don't hire the man. But by no means get upset because he has his way and you have yours. And both are fine, produce fine circumcisions, and leave baby no worse for wear with either method - it is merely a question of whether one believes one way is either better than the other, more halakhically advocated, or more vs. less painful to the baby.

I do believe other things - more globally - are worth getting upset over in the process of bris milah, such as the stories that come my way when talking to people I have just met about their experiences when they had their sons circumcised in different places and with different mohels. Thank God, most people do not have stories like these, and they are fairly uncommon, but I hear enough firsthand stories to know that they happen: mohels damaging babies, babies who lose a lot of blood and/or need to go to the hospital post-bris, of mohels who operate without gloves and who make a huge mess.

Essentially, as Phil Sherman has said it here (last paragraph), any mohel story that causes another Jew to pursue the doctor route before the baby's eighth day of life, or to choose the doctor over the ritual completely, or to forego the bris altogether, is cause enough to be upset over the disregard being fomented towards this mitzvah.

HAVING SAID ALL THIS, I AM PRODUCING THE FOLLOWING RESPONSUM FOR THE BENEFIT OF ALL THOSE INTERESTED IN THIS SUBJECT.

To the best of my knowledge, Rabbi Moshe Feinstein had three responsa on this subject. YD 1:155, 3:98, and 4:40. I am indebted to an anonymous commenter for pointing out this last one, which I am producing below, preceded by my translation of it, and commentary embedded between the "quotation indentations." Some of the points made by Rav Moshe which highlight my position have been emphasized in bold.

*******************

On
the topic of Milah and Priah at the same time, and using anesthesia on the baby
(numbing) at the time of circumcision.

This
response is the last big response that Rav Moshe wrote in his own handwriting.
During this time, his vision was deteriorating (it should not happen to
anyone), and after this response, the writing of which was very difficult for
him, he only wrote short response.

15
Elul 5744, New York

To
[many superlatives] Rabbi Shabsi/[tai?] Frankel, etc.

It's
surprising about the letter the Rabbi wrote, which is dated 16 MarCheshvan 5743,
because it has been more than 1 year and 8 months since it was written, and in
all this time, I have seen the illustrious rabbi a number of times, and he
never mentioned anything about the letter he had written. Nonetheless it has
appeared. And now that the letter has been found, and it's a matter of Torah, I
have the responsibility to respond. In particular because it is a matter that
is halakha l'mayseh (quite relevant) and on the topic of the mitzvah of
bris milah, which is very important, as the Talmud Nedarim (31b) explains.

1. Is
there a concern when the foreskin and the priah membrane are removed at the
same time with a knife of "changing the way the mitzvah is fulfilled"?

[Answer]
What the rabbi has seen in America
that the cutting of the foreskin, [along with] the membrane that is a thinner
skin – the mohel did this in one cut with his knife. This is done through the insertion
of a blunt thick needle [a probe], which he uses to separate the thin skin,
which is the membrane, from the glans.

Rav Moshe is describing the method used by many mohels to separate the membrane from the glans in order to assist in the removal of the membrane, which would otherwise remain stuck to and coating the entire penis when the foreskin is removed.

The two skins [foreskin and membrane]
were then attached, and he excised them together in one action. I was asked
this question in 5714 (1954), and my answer was published in YD I:155, that according
to the law there is no difference: not in the cutting of the foreskin or the
cutting of the membrane with regard to what they use to do it.The
mitzvah of milah is to remove the two skins that cover the glans (to the edge
of the corona), which are the foreskin and the membrane. The definition of priah
is "revealing," as Rashi explained at the end of Rabbi Eliezer
D'Milah (Shabbat137b, s"v para). And there is no difference as to how this
is accomplished.But,
since the membrane is thin and attached to the glans, and it is impossible in
practical terms, to cut it in a simple cutting of the foreskin, and it even can not [be cut] by
itself [meaning, when the foreskin has already been removed and the membrane alone remains] unless one tears it with fingernails to fold it back from on the glans;
and because it is so thin there is no need to cut it, rather they just fold it
back beyond the corona, and it sticks to the skin of the shaft in that spot and
becomes part of the shaft.

Rav Moshe is describing the third method I described at the beginning of this posting.

It
is not part of the skin of the foreskin - which is thicker – for were one to do
the same thing with the foreskin, to fold it back and have it stick below the
corona, it would be quite clear that this is the original foreskin stuck back
there. And maybe, when the circumcision is done this way [folding back extra
foreskin] he did not fulfill the mitzvah of bris milah because it will look
like it was never cut, because the skin is still there, except that it has
changed its location on the organ.
The
mitzvah is to circumcise yourselves (Genesis 17:10),
which means to completely cut off all that is recognized as that skin. And
every word "Milah" at the end of parshat Lekh Lekha and Tazria refers
to a cutting.
This
implies that for the foreskin itself, a real cutting is required. But the
membrane, which is a thin skin, which gets stuck and becomes part of the shaft
itself and can no longer be recognized, it is good enough if it was not cut and
was just folded back and set below//beyond the glans in the shaft – even though
it gets stuck there and we are aware of it.

While technically speaking Rav Moshe is obviously correct, in practical terms, I have examined many babies (in the dozens), whose parents had a concern that they did not look circumcised. In very few cases it was because not enough skin was removed. In most of the cases, not enough membrane was removed, too much was folded behind the glans, beyond the corona as Rav Moshe describes, and it became a very puffy and unsightly ring of skin which climbed its way on the glans giving the baby an uncircumcised-look. It is this concern that causes me to leave behind as little membrane as possible in most circumstances, and to leave a little more for the babies who need it to fill in the shaft.

It's
also possible that it's a "Halakah L'Moshe MiSinai," [namely] that the
foreskin needs to have a complete excision, and none of it whatsoever should
remain on the organ, not even on some other part of the organ (relocated), but
this would not be the case with the membrane.

It is not a Halakha L'Moshe MiSinai that the membrane needs to be completely removed

There is a difference between the
membrane and the foreskin, and there is a difference to the law from the decree
of the Torah, from the law from Sinai, since this is what was the practice
"l'mayseh" [for] many generations.

The practice for many generations was to remove the entire foreskin, and either to remove the membrane or to leave some of it behind.

Nonetheless,
this is certainly not to suggest there is a mitzvah to specifically leave the
membrane on the body, even in some other place [ie relocated to below the
glans]. It is certain that if a mohel removed the membrane, leaving nothing
behind, there is nothing lacking in the [fulfillment of] the mitzvah. If he's
not adding pain to the baby.

On this last comment, the question becomes one of perception: what is more painful to the baby - a hemostat and one cut? or a cut and a grab and tear of the membrane? Jury is out on that one...

And what it says in the Midrash Shochar Tov (and
in Midrash Tehillim 35:2 it only mentions [a mitzvah done with] fingernails
regarding using them to reflect the light at havdalah, but the text in Yalkut
Shimoni Tehillim 723 it mentions fingernails for priah) it says fingernails are
for priah, this is not meant to establish an obligation to do it this way.

In other words don't use conflicting midrashim which ascribe different purposes for the fingernails, in order to determine a halakha related to fingernails and their use in a bris.

It's
only because it was the practice of mohels in all the generations with
fingernails, because that way was easier to do, and it also healed better than
when [priah was] done with a knife. That's why it was done with fingernails.

This idea of it being done with the fingernails "in all generations" means that "If after the foreskin is removed there is still a membrane on the penis, the best way to remove that membrane is with a fingernail and not a knife." The knife, in that specific circumstance, is too big, too dangerous, and can't do as good a job, or as quick a job, as a fingernail. Of course, if the membrane is gone, it is a moot point. [Hmmm... but what if a mohel has more than just a knife available to use, such as a hemostat which might grab the membrane better than a fingernail...?]

But
if one sees that that the membrane is also excised with the knife, it is
simple, in my humble opinion, that he is yotze [has fulfilled the
mitzvah properly].And
this is true even if it was done in two acts – cutting the foreskin and cutting
the membrane.
And
even on shabbos, two [separate] acts are permitted, even when there is a
greater expert who can do them both [milah and priah, that is] in one act [of
cutting]

I see. Doing it in two acts is permitted, even if a "greater expert who can do both in one act" is available. So the "greater expert" is the one who can do both in one act!

And
this expert I refer to is one who is an expert in the simple cutting of the
foreskin – that he can excise all of the foreskin along with some of the
membrane, because this makes it much easier for the person doing priah to grab
the membrane.
But
many mohelim are not able to do this: when they remove the foreskin they get
nothing of the membrane. And then to go back with the knife and cut part of the
membrane is extremely difficult, and they need to find a way to begin the
cutting of the membrane, which is really a thin/delicate skin.
The
second guy, the one standing by to cut the membrane, needs to do it with his
fingernails and not a knife, because it is difficult to ascertain that he will
only cut the thin membrane with the knife [and not, chas v'shalom, a part of
the glans], unless he says he is an absolutely expert mohel. And even then we
don't rely on him.

What if he is not using a knife, Rav Moshe? What if he is using a hemostat and blunt-ended scissors to cut the membrane - in which the safety concern that a knife raises is removed with this blunt instruments?

But
in the first place, one should hire a mohel who can assure that when he removes
the foreskin he also touches the end of the membrane, so that the priah will be
relatively easy to do, with as little pain to the baby as possible.But
with regard to the fulfillment of the mitzvah of milah, there is no distinction
in the cutting of both skins together, because if both [meaning neither] skins
are not removed from the organ, it is nothing [IOW, not even considered a bris],
whereas if both skins are removed from the organ it is a fulfillment of the
mitzvah of milah.The
one distinction is that the foreskin needs to be removed completely from the
organ, but with regard to priah, when it is moved off the glans and placed
[still attached] below the corona there is that distinction because that can be
done with the membrane but cannot be done with the foreskin.

[Even in this last point I wonder, because I have been in the operating room observing a reconstruction of the penis where the entire organ needed to be drawn out of the webbing that held it inside the scrotum, and the doctor needed to use the foreskin to reconstruct the penis. In other words, what was once the foreskin is now part of the scrotum, and most of us would never notice it or know it were we to see it. Does this mean this child is not considered circumcised? His penis looks 100% circumcised... For his sake I hope it's fine, because taking away that now-part-of-his-shaft foreskin would destroy his penis.)

[I included the rest of this - which does not translate the entire answer - simply because the point is a good tag to this posting about numbing.

2.
The reason we don't use anesthesia on the baby before the circumcision

With
regard to what Rav Shlomo Zalman Auerbach wrote on 23 Cheshvan 5743 that in the
act we are careful not to change a practice, even if [the old practice] is not
a preferred way to do it.
He
said [for example]:
We
do not change how metzitzah is done, even though nowadays we have better
mediums [tools] which are much easier and better than [classic] metzitzah, and
we also do it on shabbos, even though it contains the issue of [it being]
melakha.

It seems from here that Rav Shlomo Zalman was of the opinion that a tube for metzitzah was a better method than the mouth, and that doing metzitzah on shabbos is a melakha! He allows the old ways (no pipette and doing it on shabbos) as a nod to the days of old. But his personal view of the more ancient practices is that "they are not better."

And
he also said that the reason we don't use anesthetic on the baby to prevent him
from feeling discomfort, is because we don't want to do any changes in how this
mitzvah is done, even though it would seem there is no real suspicion because
there is no indication [that this is changing the mitzvah.]

But, you should know, that the real reason we don't use anesthetic
is because anesthesia is not healthy for babies. It's also not good for older
people. But the older people take the anesthesia because they specifically
request it, because they'd much prefer to be numb [and deal with the risks that
come with anesthesia] than to feel the pain of having skin removed without
numbing. But the choice we make for children is most influenced by our concern
for their wellbeing….

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